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Abstract

Background

Patients with untreated substance use disorders (SUDs) are at risk for frequent emergency
department visits and repeated hospitalizations. Project Engage, a US pilot program
at Wilmington Hospital in Delaware, was conducted to facilitate entry of these patients
to SUD treatment after discharge. Patients identified as having hazardous or harmful
alcohol consumption based on results of the Alcohol Use Disorders Identification Test-Primary
Care (AUDIT-PC), administered to all patients at admission, received bedside assessment
with motivational interviewing and facilitated referral to treatment by a patient
engagement specialist (PES). This program evaluation provides descriptive information
on self-reported rates of SUD treatment initiation of all patients and health-care
utilization and costs for a subset of patients.

Methods

Program-level data on treatment entry after discharge were examined retrospectively.
Insurance claims data for two small cohorts who entered treatment after discharge
(2009, n = 18, and 2010, n = 25) were reviewed over a six-month period in 2009 (three
months pre- and post-Project Engage), or over a 12-month period in 2010 (six months
pre- and post-Project Engage). These data provided descriptive information on health-care
utilization and costs. (Data on those who participated in Project Engage but did not
enter treatment were unavailable).

Results

Between September 1, 2008, and December 30, 2010, 415 patients participated in Project
Engage, and 180 (43%) were admitted for SUD treatment. For a small cohort who participated
between June 1, 2009, and November 30, 2009 (n = 18), insurance claims demonstrated
a 33% ($35,938) decrease in inpatient medical admissions, a 38% ($4,248) decrease
in emergency department visits, a 42% ($1,579) increase in behavioral health/substance
abuse (BH/SA) inpatient admissions, and a 33% ($847) increase in outpatient BH/SA
admissions, for an overall decrease of $37,760. For a small cohort who participated
between June 1, 2010, and November 30, 2010 (n = 25), claims demonstrated a 58% ($68,422)
decrease in inpatient medical admissions; a 13% ($3,308) decrease in emergency department
visits; a 32% ($18,119) decrease in BH/SA inpatient admissions, and a 32% ($963) increase
in outpatient BH/SA admissions, for an overall decrease of $88,886.

Conclusions

These findings demonstrate that a large percentage of patients entered SUD treatment
after participating in Project Engage, a novel intervention with facilitated referral
to treatment. Although the findings are limited by the retrospective nature of the
data and the small sample sizes, they do suggest a potentially cost-effective addition
to existing hospital services if replicated in prospective studies with larger samples
and controls.

Keywords:

Background

Alcohol and drug use are associated with a variety of medical conditions
[1,2] and carry high global burdens of disease, injury, and cost
[3,4]. Substance use is associated with inadequate ambulatory care utilization and poor
health outcomes
[5], and people with substance use are over-represented among frequent consumers of emergency
department (ED)
[6] and inpatient
[7] medical services. Substance abuse is predictive of discharge against medical advice
[8], and inpatients discharged with substance use disorder (SUD) diagnoses, particularly
drug-related diagnoses, have higher rates of recurrent ED and medical inpatient service
utilization
[9]. This is not only associated with unnecessary human suffering but also generates
disproportionately high health-care costs
[10].

Hospital medical units are aggregators of people with SUDs, and hospitalization itself
could serve as a “reachable moment” to intervene with these patients and engage them
in appropriate SUD treatment after discharge
[11]. In-hospital interventions to help patients enter SUD treatment might improve this
situation, and such programs are likely to receive heightened attention since the
Patient Protection and Affordable Care Act
[12] will reduce Medicare payments to hospitals with excess readmissions beginning in
October 2012.

In September 2008, leadership at Wilmington Hospital in the US state of Delaware collaborated
with Brandywine Counseling and Community Services (BCCS), a major provider of SUD
treatment in Delaware, to develop and implement Project Engage, a pilot program to
identify medical and surgical inpatients with problematic substance use and to help
them enter SUD treatment after discharge. Wilmington Hospital is a 241-bed general
hospital owned and operated by Christiana Care Health System (CCHS), one of the largest
health-care providers in the US mid-Atlantic region. Christiana Care Health System
serves the state of Delaware and portions of seven New Jersey, Pennsylvania, and Maryland
counties. In 2011, Wilmington Hospital recorded 52,178 ED visits and 13,778 medical
and surgical admissions.

Project Engage has its theoretical basis in the literature on brief intervention (BI)
to address excessive alcohol use among primary care outpatients
[13]; BI for risky drinking and alcohol dependence among medical inpatients
[14,15]; and screening, BI, and referral to treatment (SBIRT) for patients with moderate
to high risk alcohol and/or drug use or dependence in diverse medical settings, including
primary care, EDs, trauma centers, and inpatient and outpatient medical hospital services
[16-18].

Studies reported in this literature have had promising outcomes. Patients in a large,
federally funded SBIRT study conducted in six states reported decreases in illicit
drug and heavy alcohol use subsequent to participation
[16]. Studies of SBIRT in EDs have demonstrated decreased health-care costs and inpatient
utilization
[17] and increased rates of admissions to SUD treatment
[19]. Randomized trials of BI for excessive alcohol use among primary care outpatients
[13] have shown significant reductions in self-reported drinking. Data from screening
and BI (SBI) for primary care outpatients with unhealthy nondependent alcohol use
[13] led the US Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
to include performance measures for its use in hospitals
[20].

Although these lines of research are significant, they have important gaps. For example,
most published studies have applied BI to patients with unhealthy or risky drinking,
alcohol abuse, and/or alcohol dependence. In reality, alcohol and drug problems are
frequently comorbid, and patients with alcohol and drug problems—or primary drug problems—are
also in need of care. Further, the majority of BI studies demonstrated efficacy in
reducing alcohol use when alcohol-dependent individuals were excluded
[21,22]; however, patients with alcohol dependence constitute the majority of medical inpatients
with alcohol problems
[23] and have a great need for SUD treatment. A literature search revealed a paucity of
published studies of alcohol and drug BI or SBIRT conducted exclusively with hospital
inpatients. Finally, hospitalized patients with SUDs often face multiple barriers
to accessing treatment including homelessness, brief lengths of stay complicating
discharge planning, ambivalence, and inadequate transfer resources
[24]. These problems require an increased emphasis on referral to treatment. Since the
chances of engaging patients in treatment decrease with the length of time between
assessment and treatment admission
[25], facilitated admission could be particularly important for this population.

Description of the project engage pilot program

In many cases, SUDs directly or indirectly contribute to health problems leading to
hospitalization. Patients with SUDs are often well known to hospital staff, but clinical
teams typically have little training or experience in addressing SUDs. In fact, hospital
personnel are often frustrated with these patients due to frequent rehospitalizations,
noncompliance with recommendations to cut back or abstain, and resistance to entering
and staying in SUD treatment. Project Engage, a modified version of BI and SBIRT,
was designed to provide bedside assistance for the clinical team to address these
problems. It consists of SUD identification by hospital staff based on clinical impressions
but without a universal standardized screening process to identify alcohol and drug
problems, followed by BI and facilitated referral to treatment (FRT). Although there
are efforts to identify patients, this does not constitute “screening” because a universal,
standardized approach to identification is not employed. Referral to treatment is
enhanced by facilitation. The Project Engage pilot program described here was not
designed as a research study, although self-report data on initiation of SUD treatment
by Project Engage patients after discharge were collected, and insurance-claims data
on two small cohorts of patients were examined retrospectively.

Identification

Hospital clinical staff identified patients with possible alcohol and/or drug problems
per usual procedures. Before Project Engage was initiated, brief trainings were provided
to nursing staff on how to identify patients with problematic drug or alcohol use.
The potential value of connecting them to treatment was emphasized, and an overview
of the Project Engage program along with contact information for Project Engage staff
was provided. In October 2009, the Alcohol Use Disorders Identification Test-Primary
Care (AUDIT-PC)
[26-28], a five-item self-report instrument to detect “hazardous and harmful alcohol consumption
[29],” was initiated system-wide at CCHS to detect patients at risk for alcohol withdrawal
and delirium tremens (DTs), and nursing staff administered it to all medical/surgical
inpatients at admission.

Patients were identified for possible inclusion in Project Engage if they met any
of the following criteria: clinical suspicion of alcohol and/or drug abuse or dependence;
hospital admission likely related to alcohol and/or drug abuse or dependence; positive
result on a drug test; AUDIT-PC ≥ 5 (as of October 2009); primary, secondary, or tertiary
diagnosis related to substance use; or self-reported past or current alcohol and/or
drug use. Patients under age 18 or with senility, dementia, or other disorders that
interfered with the ability to provide informed consent to be seen by a non-CCHS provider
were excluded from Project Engage. Nursing staff provided eligible patients with a
choice to participate—or not participate—in Project Engage. Although Project Engage
was not a research study, patients who chose to participate in it signed a “Choice
Form” as part of an informed-consent process required in order to be seen by a non-CCHS
provider. (The patient engagement specialists [PESs] were employed by BCCS.) Unfortunately,
the number of patients who were identified and approached for participation, the number
of interventions received by each patient, and the number of Project Engage patients
who were unwilling to accept a referral were not recorded.

Brief intervention

Patients who chose to participate in Project Engage received a BI from a PES hired
specifically for the project. Project Engage specialists were in stable recovery from
alcohol and/or drugs (at least two years without drug or alcohol use) and selected
on the basis of emotional stability, experience in recovery, and interpersonal strengths.
They received training in working in a health-care setting, co-occurring disorders,
rapport building, basic interviewing techniques, assessment, motivational interviewing
(MI), treatment referral, and ethics and were regularly supervised by licensed chemical-dependency
professionals.

The BI occurred while patients were hospitalized and consisted of rapport building,
a brief assessment, and one or two brief motivational interviewing (MI) sessions
[30] to enhance patient motivation to attend SUD treatment and accept a facilitated referral.
The purpose of the assessment was to determine if patients might benefit from SUD
treatment and to identify possible barriers to transitioning them into it. The PESs
used the Delaware Division of Substance Abuse and Mental Health (DSAMH) Co-Occurring
Conditions Screening Instrument in conjunction with information gathered during MI
sessions and the DSAMH/American Society of Addiction Medicine (ASAM) Crosswalk to
match patient treatment needs to treatment programs according to ASAM’s Patient Placement
Criteria-2nd Revision (ASAM PPC-2R
[31]). If treatment slots in appropriate Delaware programs were not available, patients
received facilitated referrals to programs in neighboring states.

Facilitated referral to treatment

When patients were willing to consider SUD treatment, the PESs provided them with
facilitated referrals as follows: They discussed potential treatment programs, and
when patients agreed to consider a program, the PESs determined whether that program
had an opening, whether it accepted the patient’s insurance or could admit him/her
with other funding, and (if both these conditions were met) made an appointment for
a time that was convenient to the patient. Patients who were in need of treatment
and willing to accept a referral received a date and time for an appointment or inpatient
admission rather than the name and phone number of a program. For programs that required
the Addiction Severity Index
[32], PESs administered it at bedside if patients were willing to complete it. The PESs
also assessed potential barriers to treatment initiation such as homelessness, transportation
difficulties, or lack of appropriate clothing. When necessary, patients were given
bus or train tickets, driven to the treatment program, or picked up by the treatment
program upon discharge. The PESs also contacted shelters for housing, acquired clothing
for patients in need, and called patients within 48 hours after their scheduled admission
or appointment to confirm that they attended. When patients reported having gone to
treatment, PESs gave positive feedback and encouraged them to continue; when patients
reported that they had not gone to treatment, PESs attempted to problem-solve any
barriers and left the door open for future contact to facilitate admissions or appointments.

Methods

The Project Engage pilot at Wilmington Hospital was not prospectively designed as
a research study; however, program-level data on patients’ self-reported initiation
of SUD treatment, as well as a description of health-care utilization before and after
the intervention for two small cohorts of Project Engage patients who entered SUD
treatment, were available from a single health plan and are presented here.

Participants

Participants included all Project Engage patients seen between 9/1/2008 and 12/30/2010
(n = 415) as well as two smaller groups of patients who received the Project Engage
intervention, initiated SUD treatment after discharge, and had uninterrupted insurance
coverage and complete claims data three months before and three months after the intervention
(2009 group) (n = 18) or six months before and six months after the intervention (2010
group) (n = 25).

Of the 415 patients seen between September 1, 2008, and December 30, 2010, 275 (65%)
were male, and 135 (33%) were female (5 did not self-identify as either gender); 201
(48%) were white, 188 (45%) were black, and 26 (6%) self-identified as mixed race
or other. The average age of patients was 46 years (SD, 11.8 years), and 183 (44%)
were ≥50 years. Regarding their primary substance of choice (some were multiple),
240 (58%) reported alcohol, 90 (22%) reported crack or powder cocaine, 64 (15%) reported
heroin, 17 (4%) reported marijuana, 11 (3%) reported an opioid other than heroin,
5 (0.01%) reported benzodiazepines, and 4 (0.01%) reported methamphetamines.

The two smaller cohorts consisted of all patients insured by Delaware Physicians Care
Incorporated (DPCI) who had uninterrupted coverage and complete claims data. The 2009
cohort participated in Project Engage between June 1, 2009, and November 30, 2009,
and consisted of nine men and nine women. The average age was 43 years (SD, 10 years).
The 2010 cohort participated in Project Engage between June 1, 2010, and November
30, 2010, and consisted of 12 men and 13 women. The average age was 40 years (SD,
12 years). Unfortunately, the small number of patients meeting inclusion criteria
(uninterrupted coverage and complete claims data) did not allow for random selection.

Data analytic strategy

Brandywine Counseling and Community Services furnished program-level data on the number
of patients who participated in Project Engage between September 1, 2008, and December
30, 2010, and on self-reported SUD treatment initiation after discharge. Delaware
Physicians Care Incorporated provided claims data for two smaller cohorts. Christiana
Care Health System’s Institutional Review Board approved queries to BCCS’s Project
Engage records to determine rates of treatment initiation and the use of data from
DPCI’s reports for a poster presentation
[33] and this article. Unfortunately, the DPCI datasets from which the reports were generated
were not available to the authors, so detailed health economic analyses were not possible.

Results

Program-level data: Participant admissions to SUD treatment

Between September 1, 2008, and December 30, 2010, 415 patients participated in Project
Engage. (The number of patients identified and approached for participation was not
recorded.) Of these patients, 180 (43%) were admitted to an inpatient treatment program
and/or attended one or more session(s) at an outpatient program. Of these patients,
16 (8%) were admitted to inpatient detoxification; 53 (29%) were admitted to residential
treatment; 103 (57%) were admitted to outpatient treatment; and 8 (4%) were admitted
to transitional housing and treatment (Table
1).

Table 1.Admissions to substance abuse treatment for project engage patients seen between September
1, 2008, and December 30, 2010 (N = 415)

Cohort-level data: Health-care utilization and costs before and after participation
in project engage

Delaware Physicians Care Incorporated provided health-care utilization and costs for
inpatient medical admissions, ED visits, and inpatient and outpatient behavioral health/substance
abuse (BH/SA) admissions before and after the 2009 and 2010 subgroups received the
Project Engage intervention (DPCI was not able to differentiate between BH and SA
treatment in reported outcomes). The hospitalization during which patients received
the Project Engage intervention was not included in these costs, but SUD treatment
costs after hospitalization were included.

Of the 18 patients in 2009 subgroup who initiated SUD treatment after discharge, five
had at least one BH/SA outpatient visit subsequent to the Project Engage intervention,
and six had at least one inpatient BH/SA admission. There was a 33% ($35,938) decrease
in inpatient medical admissions in this subgroup, a 38% ($4,248) decrease in ED visits,
a 42% ($1,579) increase in BH/SA inpatient admissions, and a 33% ($847) increase in
outpatient BH/SA admissions, for an overall cost decrease of $37,760 (Table
2).

Of the 25 patients in the 2010 subgroup who initiated SUD treatment after discharge,
13 had at least one BH/SA outpatient visit subsequent to the Project Engage intervention,
and 9 had at least one inpatient BH/SA admission. a 58% ($68,422) decrease in inpatient
medical admissions; a 13% ($3,308) decrease in emergency department visits; a 32%
($18,119) decrease in BH/SA inpatient admissions, and a 32% ($963) increase in outpatient
BH/SA admissions, for an overall decrease of $88,886 (Table
2).

Discussion

Although this pilot program was not designed as a research study, retrospective evaluation
of the data yielded useful descriptive information. Project Engage involved collaboration
between a large hospital system, an SUD treatment provider, and a health plan and
demonstrated that such collaboration is possible in a clinical setting. It also demonstrated
that cost data (although limited) can be obtained outside the context of a formal
research study. Importantly, FRT (a major component of Project Engage) is an innovative
approach that warrants further study to assess its impact on treatment enrollment.
The use of PESs rather than graduate students or licensed clinicians differs from
approaches common in the existing BI and SBIRT literature. The success of Project
Engage suggests interventions delivered by such individuals are accepted by patients
and could be used in these and other settings.

The finding that a relatively large proportion (43%) of Project Engage patients entered
SUD treatment after discharge is promising. Krupski et al.
[19] examined admissions to treatment subsequent to BI (MI without referral to treatment)
in ED patients who screened positive for alcohol and/or other drug problems and found
that 34% of those who received the intervention were admitted to SUD treatment within
12 months compared with 23% of those who did not receive it. Saitz et al.
[14] studied a BI (single MI session without referral to treatment) for medical inpatients
with risky drinking or alcohol dependence and found that, among alcohol-dependent
patients, 49% of the MI group and 44% of the control group attended alcohol treatment
within three months; between-group differences were not significant. Our results are
comparable but included patients who may have had alcohol and/or drug abuse and dependence and were collected within 48 hours of patients’ scheduled
admissions or appointments. It is possible that these numbers could have changed three
or 12 months after the intervention.

The preliminary findings concerning apparent differences in health-care costs before
and after the intervention in the two smaller patient cohorts are also encouraging,
as they reflect less medical and more BH/SA treatment utilization in the post-hospitalization
period; however, they cannot definitively be considered cost savings due to a number
of limitations. These include the absence of formal substance-use diagnoses; the lack
of a control condition; the retrospective nature of data collection; the lack of data
on the number of patients approached who declined to participate in Project Engage;
the lack of data on the number of patients for whom a referral to treatment was not
considered necessary; and differences in the specific characteristics of facilitated
referrals. Because of these limitations, no conclusions can be drawn about causation.
Also, the data on health-care costs were based on previously completed reports, the
datasets for which were not released to the authors; thus further analyses were not
possible.

Based on available findings, one can only conclude that a relatively large number
(43%) of patients who received the Project Engage intervention entered SUD treatment,
and differences in overall health-care costs were observed after participation. It
is possible that these outcomes were affected by selection bias in that those patients
who were most likely to participate in Project Engage and enter SUD treatment were
also less likely to utilize medical health-care services. However, according to the
literature, hospitalized patients like those who participated in Project Engage have
not accessed substance abuse treatment by the usual referral processes. From the authors’
perspective, it is possible that engaging these patients in SUD treatment reduced
their health-care utilization and costs by addressing their SUDs; however, this is
impossible to prove due the limitations of these data. From the perspective of the
payer, creating a portal for these patients to enter addiction treatment makes sense
as a potential way to reduce health-care costs.

Conclusions

Despite limitations, these results provide useful pilot data to justify prospective,
controlled studies of similar interventions including FRT for medically hospitalized
patients. Key next steps for Project Engage include refining the model to incorporate
lessons learned; identifying potential sources of support; and examining potential
pre-/post-participation differences in health-care costs with appropriate economic
analyses. A standardized approach to screening may help hospital clinical staff to
identify more patients in the future. It would also be useful to examine the role
of FRT in greater detail. Randomized controlled trials comparing an intervention with
FRT to an intervention without FRT are necessary. To increase the accuracy of endpoint
measurement, it would be helpful to collect outcome data at six-months post-discharge
that includes confirmation of attendance at treatment programs, self-reported substance
use, urinalysis, and breath testing. Finally, this study looked at admissions to SUD
treatment, not retention. It is well known that many patients admitted to addiction
treatment do not remain in treatment
[34]. Subsequent studies should investigate both admissions and retention. If retention
is problematic, an adaptive continuing care component
[35] could be added to future iterations of the Project Engage intervention. Due to these
favorable initial findings described here and anonymous financial support, Project
Engage was retained at Wilmington Hospital and initiated at Christiana Hospital in
the fall of 2011. A prospective study of the intervention is underway.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

AP coordinated inter-institutional collaboration for this program evaluation, reviewed
the literature, drafted and edited the manuscript, guided queries on specific data
points by BCCS and DPCI where possible, and prepared the manuscript for submission.
TH developed the idea for Project Engage, collaborated with community partners, implemented
the program at Wilmington Hospital, reviewed the literature, and reviewed and edited
paper. EE reviewed and edited the manuscript. JB reviewed and edited the manuscript
and helped to identify endpoints for future studies. PAW coordinated DPCI’s collaboration
with Wilmington Hospital, provided reports on data analyses that were incorporated
into the manuscript, and reviewed and edited the manuscript. BS led the BCCS team,
trained and supervised the PESs, managed program-level data, participated in meetings
between CCHS and BCCS staff, and reviewed and edited the manuscript. PM wrote the
IRB application and reviewed and edited the manuscript. GW drafted and edited the
manuscript. All authors read and approved the final manuscript.

Financial support

This research was supported by a Christiana Care Community Services and Education
Grant (Project Engage), NIDA grant U10 DA-13043 (AP), and NIDA U10 DA-13043 and KO5
DA-17009 (GW).

Acknowledgments

We wish to acknowledge DPCI and BCCS; Bobbi Dillard, the PES during most of Project
Engage’s pilot phase; and all of the clinical staff at Wilmington Hospital for contributing
to the success of this pilot project. We also wish to thank all of the patients who
participated in the program. We wish to thank the Carol A. Ammon Foundation for its
ongoing, generous support of Project Engage.